Jennifer Leaning

The political origins of health inequity: prospects for change

Ole Petter Ottersen, Jashodhara Dasgupta, Chantal Blouin, Paulo Buss, Virasakdi Chongsuvivatwong, Julio Frenk, Sakiko Fukuda-Parr, Bience P Gawanas, Rita Giacaman, John Gyapong, Jennifer Leaning, Michael Marmot, Desmond McNeill, Gertrude I Mongella, Nkosana Moyo, Sigrun Møgedal, Ayanda Ntsaluba, Gorik Ooms, Espen Bjertness, Ann Louise Lie, Suerie Moon, Sidsel Roalkvam, Kristin I Sandberg, Inger B Scheel

Assistance, protection, and governance networks in complex emergencies

This article presents an introduction to the causes and characteristics of armed conflicts. It reviews some of the key humanitarian crises that broke new ground in terms of the technologies and practices that developed at the field level in response to each new complex emergency, with particular focus on the health sector. It introduces the concept of humanitarian governance as a framework for addressing the consequences and implications of the failure of worldwide governance for the protection of civilians in armed conflict. Here, we term humanitarian governance to include the use of international humanitarian law and human rights instruments to govern the behaviour of state and non-state organisations in conflict zones in a way that protects the lives and livelihoods of affected populations. We note, however, that terrorist concerns appear to be replacing humanitarian logic in the network of worldwide governance.

Costs of Inaction on Maternal Mortality: Qualitative Evidence of the Impacts of Maternal Deaths on Living Children in Tanzania

Background Little is known about the interconnectedness of maternal deaths and impacts on children, beyond infants, or the mechanisms through which this interconnectedness is established. A study was conducted in rural Tanzania to provide qualitative insight regarding how maternal mortality affects index as well as other living children and to identify shared structural and social factors that foster high levels of maternal mortality and child vulnerabilities. Methods and Findings Adult family members of women who died due to maternal causes (N = 45) and key stakeholders (N = 35) participated in in-depth interviews. Twelve focus group discussions were also conducted (N = 83) among community leaders in three rural regions of Tanzania. Findings highlight the widespread impact of a woman’s death on her children’s health, education, and economic status, and, by inference, the roles that women play within their families in rural Tanzanian communities. Conclusions The full costs of failing to address preventable maternal mortality include intergenerational impacts on the nutritional status, health, and education of children, as well as the economic capacity of families. When setting priorities in a resource-poor, high maternal mortality country, such as Tanzania, the far-reaching effects that reducing maternal deaths can have on families and communities, as well as women’s own lives, should be considered.

Consequences of maternal mortality on infant and child survival: a 25-year longitudinal analysis in Butajira Ethiopia (1987-2011)

AbstractaBackgroundMaternal mortality remains the leading cause of death and disability for reproductive-age women in resource-poor countries. The impact of a mother’s death on child outcomes is likely severe but has not been well quantified. This analysis examines survival outcomes for children whose mothers die during or shortly after childbirth in Butajira, Ethiopia.MethodsThis study uses data from the Butajira Health and Demographic Surveillance System (HDSS) site. Child outcomes were assessed using statistical tests to compare survival trajectories and age-specific mortality rates for children who did and did not experience a maternal death. The analyses leveraged the advantages of a large, long-term longitudinal dataset with a high frequency of data collection; but used a strict date-based method to code maternal deaths (as occurring within 42 or 365 days of childbirth), which may be subject to misclassification or recall bias.ResultsBetween 1987 and 2011, there were 18189 live births to 5119 mothers; and 73 mothers of 78 children died within the first year of their child’s life, with 45% of these (n=30) classified as maternal deaths due to women dying within 42 days of childbirth. Among the maternal deaths, 81% of these infants also died. Children who experienced a maternal death within 42 days of their birth faced 46 times greater risk of dying within one month when compared to babies whose mothers survived (95% confidence interval 25.84-81.92; or adjusted ratio, 57.24 with confidence interval 25.31-129.49).ConclusionsWhen a woman in this study population experienced a maternal death, her infant was much more likely to die than to survive—and the survival trajectory of these children is far worse than those of mothers who do not die postpartum. This highlights the importance of investigating how clinical care and socio-economic support programs can better address the needs of orphans, both throughout the intra- and post-partum periods as well as over the life course.

New challenges for humanitarian protection

The fourth Geneva Convention, adopted 50 years ago, on 12 August 1949, describes the actions that warring parties must take to protect civilian populations from the worst excesses of war. Building on the concept developed in the previous three conventions—that certain activities and people, especially civilians, can be seen as hors de combat—the fourth Geneva Convention defines in detail the many ways in which civilians must be dealt with to shield them from the direct and indirect effects of conflict between combatant forces. Among the responsibilities that this convention sets for the warring parties are explicit actions that would grant medical personnel, and all aspects of the medical enterprise, complete protection from interference or harm. This neutral status for medical relief (and, by extension, all humanitarian aid) rests on the reciprocal assumption that those who deliver this relief are practising in accord with their professional ethics and will take specified steps to maintain their neutral posture vis a vis the warring parties. The moral impetus for this addition to the Geneva Conventions derived from international reaction to the great civilian death toll of the second world war. In virtually all wars of the subsequent 50 years the fourth Geneva Convention has been variously observed and routinely violated—and there has been no calling to account. Moreover, and this is what prompts new attention to the issue of humanitarian protection in war, in recent wars the warring parties have shown an increasing tendency to flout the fourth convention entirely. The problem is no longer a failure to abide by the rules but a failure to acknowledge that the rules even exist.1 This failure is particularly relevant for the medical community. Without the guarantees of protection defined in the fourth convention, civilians can be slaughtered with impunity and physicians and other relief …

Militarized Sexual Violence in South Kivu, Democratic Republic of Congo

Eastern DRC has been the site of a protracted conflict in which sexual violence has been a defining feature. The method used was a retrospective registry-based study of sexual violence survivors presenting to Panzi Hospital between 2004 and 2008. This analysis aimed to describe the patterns of sexual violence described by survivors and to analyze perpetrator profiles. As regards results, a total of 4,311 records were analyzed. Perpetrators in this data set were identified as follows: (a) 6% were civilians; (b) 52% were armed combatants; and (c) 42% were simply identified as “assailant(s)” with no further identifying information. Those identified simply as “assailants” perpetrated patterns of sexual violence that were similar to those of armed combatants, suggesting that this group included a large number of armed combatants. Civilian assailants perpetrated a pattern of sexual violence that was distinct from armed combatants. Conclusions are as follows: These data suggest that a high proportion of sexual assaults in South Kivu are perpetrated by armed combatants. Protection of women in South Kivu will require new strategies that take into account the unique nature of sexual violence in DRC. Engaging with local communities, the UN and other aid organizations is necessary to create new context-appropriate protection programs.

Connectedness, social support and internalising emotional and behavioural problems in adolescents displaced by the Chechen conflict

The study investigated factors associated with internalising emotional and behavioural problems among adolescents displaced during the most recent Chechen conflict. A cross-sectional survey (N=183) examined relationships between social support and connectedness with family, peers and community in relation to internalising problems. Levels of internalising were higher in displaced Chechen youth compared to published norms among non-referred youth in the United States and among Russian children not affected by conflict. Girls demonstrated higher problem scores compared to boys. Significant inverse correlations were observed between family, peer and community connectedness and internalising problems. In multivariate analyses, family connectedness was indicated as a significant predictor of internalising problems, independent of age, gender, housing status and other forms of support evaluated. Sub-analyses by gender indicated stronger protective relationships between family connectedness and internalising problems in boys. Results indicate that family connectedness is an important protective factor requiring further exploration by gender in war-affected adolescents.

Demographics and Care-Seeking Behaviors of Sexual Violence Survivors in South Kivu Province, Democratic Republic of Congo

OBJECTIVES One of the most striking features of the ongoing conflict in the Democratic Republic of Congo (DRC) is the use of sexual violence. In spite of the brutality of these crimes, the experiences of women affected by sexual violence in Eastern DRC remain poorly characterized. This analysis aimed to (1) provide detailed demographics of sexual violence survivors presenting to Panzi Hospital; (2) examine how demographic factors might impact patterns of sexual violence; and (3) describe care-seeking behavior among sexual violence survivors. METHODS The demographics and care-seeking behavior of sexual violence survivors in South Kivu Province were described from a retrospective registry-based study of sexual violence survivors presenting to Panzi Hospital (2004-2008). RESULTS A total of 4311 records were reviewed. The mean age of survivors was 35 years. Most women (53%) were married, self-identified with the Bashi tribe (65%), and reported agriculture as their livelihood (74%). The mean time delay between sexual assault and seeking care was 10.4 months. Five reasons were identified to help explain the lengthy delays to seeking care: waiting for physical symptoms to develop or worsen before seeking medical attention, lack of means to access medical care, concerns that family would find out about the sexual assault, stigma surrounding sexual violence, and being abducted into sexual slavery for prolonged periods of time. CONCLUSIONS Many sexual assault survivors have very delayed presentations to medical attention. Promoting timely access of medical care may best be facilitated by reducing stigma and by educating women about the benefits of early medical care, even in the absence of injuries or symptoms.

Public health equity in refugee situations

Addressing increasing concerns about public health equity in the context of violent conflict and the consequent forced displacement of populations is complex. Important operational questions now faced by humanitarian agencies can to some extent be clarified by reference to relevant ethical theory. Priorities of service delivery, the allocation choices, and the processes by which they are arrived at are now coming under renewed scrutiny in the light of the estimated two million refugees who fled from Iraq since 2003.Operational questions that need to be addressed include health as a relative priority, allocations between and within different populations, and transition and exit strategies. Public health equity issues faced by the humanitarian community can be framed as issues of resource allocation and issues of decision-making. The ethical approach to resource allocation in health requires taking adequate steps to reduce suffering and promote wellbeing, with the upper bound being to avoid harming those at the lower end of the welfare continuum. Deliberations in the realm of international justice have not provided a legal or implementation platform for reducing health disparities across the world, although norms and expectations, including within the humanitarian community, may be moving in that direction.Despite the limitations of applying ethical theory in the fluid, complex and highly political environment of refugee settings, this article explores how this theory could be used in these contexts and provides practical examples. The intent is to encourage professionals in the field, such as aid workers, health care providers, policy makers, and academics, to consider these ethical principles when making decisions.

Human rights and medical education

The Universal Declaration of Human Rights enters its 50th anniversary year in 1998. Around the world efforts are under way to celebrate this event and accelerate efforts to disseminate the contents of the declaration. These efforts are undertaken in recognition that progress has been at best uneven since that early morning of 10 December 1948 when the United Nations General Assembly formally adopted this document and thereby sought to enshrine in world consciousness a commitment to secure basic human rights around the world. In 1948 there were 58 member nations of the UN; there are now 185. For this world community the declaration has acquired the status of international law and all governments can be held to its principles. Many other international treaties and charters have incorporated the language of the declaration or referred to it; and many national governments have included its language and principles in their constitutions.1 The declaration encompasses civil and political rights of individuals (in the first 21 articles); economic and social rights, including to health care (articles 22-27); and reciprocal obligations and constraints conferred by participation in a community (articles 28-30) (see p 1455). There are several histories of this document which are relevant to those interested in the struggle to persuade human beings to find common ground and push off to higher reaches from it. Yet for the medical community in general, and for the subset who are medical students, the history is less crucial than is the fact of what this document now has become, 50 years from its making. With astonishing durability it has withstood the test of time and has become the minimum consensus statement …